Posts tagged direct access
90% Of Patients With Back Pain Are Not Referred To Physical Therapy After Seeing Primary Care First

Low back pain, along with death and taxes, remains one of the certainties of life. This condition affects over 90% of Americans and is often benign, but painful, in nature. Currently spending on low back pain is over 100 billion dollars a year and much of this spending can be attributed to unnecessary and unwarranted tests and interventions including early imaging (x ray, MRI, CT scans), advanced procedures (injections, surgery) abnd office visits. Consistent with many musculoskeletal conditions, early treatment of acute low back pain accelerates a patient’s recovery and may be our best strategy at reducing health care spending and excessive treatments. Our previous blog posts have highlighted the benefits of direct access to Physical Therapy services or patient self referral including cost savings of $1000-1500 per episode of care. Despite the clinical and cost effective benefits of Physical Therapy, a recent study highlights the limitations of seeing a primary care physician first for low back pain.


Authors in the journal Spine analyzed over 170 million medical office visits for low back pain between 1997 and 2010 to determine health care utilization rates for this condition (Zheng et al. 2017). Authors found on average only 10% of patients with low back pain were referred to Physical Therapy after seeing a physician first and this rate remained stagnant over the study time period. Lower referral rates were found for patients covered by Medicare and Medicaid. Conversely, opiod prescriptions increased from 15% to 45% through the study’s 13 years of data collection. Authors found patients not referred to Physical Therapy were more likely to receive an opioid prescription.

Patients are encouraged to utilize direct access or advocate for a Physical Therapy referral for early treatment of their back pain symptoms.

Research Supports Physical Therapists As Primary Care Providers For Musculoskeletal Conditions
physical-therapy-direct access-effectiveness

Evidence continues to support the utilization of Physical Therapists as a first line treatment for patients with musculoskeletal conditions such as back, neck, shoulder, or knee pain. Patient self referral for Physical Therapy services or direct access has been safely utilized in our country since the late 1950s. Many large corporations and the U.S. Military utilize this model of care due to its’ clinical and cost effectiveness. Patient’s seen by a Physical Therapist first save on average $1000-1500 per episode of care. This model allows patients to access high quality care quickly after the onset of an injury avoiding lost time and money associated with delays in the traditional healthcare system.

Bornhoft and colleagues randomized patients from 3 medical clinics with musculoskeletal disorders to either a primary care physician or Physical Therapist (Ther Adv Musculoskeletal Dis. 2019). Patients were followed at 2, 12, 26, and 52 weeks after the initial consultation with a medical provider. Authors were interested in a patient’s symptoms, function, quality of life, and risk for developing chronic musculoskeletal symptoms. They found both groups of patients improved but consistently better outcomes in the group treated by Physical Therapists. The authors concluded Physical Therapists can be safely and effectively recommended as an alternative management pathway for patients with musculoskeletal conditions.

Early Physical Therapy Associated With Reduced Long Term Opioid Use

Each day over one hundred Americans die from an opioid overdose. Over prescription and use of prescription pain relievers has largely contributed to these unnecessary deaths and the $78 billion dollar economic burden of the opioid epidemic. Authors estimate over 2 million Americans are currently suffering from a substance abuse disorder related to these prescriptions. Experts are now recommending non pharmaceutical pain relieving alternatives including meditation and Physical Therapy. Research strongly points to the early utilization of Physical Therapy as a safe, clinically and cost effective intervention for patients suffering from musculoskeletal pain. A new research study Physical Therapists may play in the opioid epidemic.

The Journal of the American Medical Association published a review article on the impact of early Physical Therapy on the utilization of opioid medication (Sun et al. 2018). Authors reviewed the cases of over 88,000 patients with neck, back, knee, or shoulder pain. Patient cases were then reviewed retrospectively to determine the type and amount of interventions utilized to treat these patient’s symptoms. Authors reported early Physical Therapy was associated with a significant reduction in the amount of opioids prescribed and the duration of these prescriptions. Authors recommended Physical Therapy as a first line intervention for a treatment of these musculoskeletal conditions.

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Physical Therapy First Reduces Opioid use, ER visits, and Healthcare Costs in patients with low back pain

The evidence and momentum continue to build for seeing a Physical Therapist first for patients with low back pain.  Physical Therapists have continually been shown to be clinically and cost effective providers for low back pain conditions.  This approach, direct access to Physical Therapy, has been utilized by large hospital systems and Fortune 500 companies to both accelerate a patient's recovery and reduce health costs.  Studies report up to $1500 in cost savings when using this approach secondary to decreased utilization of health care services include office visits, medications, imaging, and surgery.


A recent study followed patients with a recent onset of low back pain over a one year period (Frogner et al. Health Services Research. 2018).  Participants healthcare utilization was calculated based on whether they saw a Physical Therapist first, a Physical Therapy later, or were not prescribed Physical Therapy.  Consistent with the existing literature, patients who were seen by a Physical Therapist first had a 90% lower probability of being prescribed an opioid, as well as, lower rates of emergency department and imaging services.  The lower utilization of healthcare services were reflected in the significant cost savings found in the PT first group.

Contact the experts at MEND to learn how to resolve your low back pain symptoms

Should I see a Physical Therapist or a Physician first for my pain?

Time and money are two finite resources especially in today's healthcare environment of rising deductibles and decreased access to primary care services.  Thankfully in Colorado patients have a choice on who to see first for their muscle, tendon, and joint pain.  State law enables Coloradans to see a Physical Therapist without a prior referral.  This care model, direct access, has been utilized since the early 1950's to reduce costs and improve outcomes for patients with musculoskeletal pain.  Currently, fortune 500 companies, the U.S. military, and large hospital systems utilize this model of care due to its' safety, cost and clinical effectiveness, and ability to decrease wait times for patients.  Below is a summary of the latest research comparing cost and prognosis for seeing a PT first for your musculoskeletal pain.

Low Back Pain – 2nd most common reason patients seek medical attention

            Patients save $1996 if they see a PT first vs. guideline based care (Hahne et al. 2016)

            Patients saved $1543 if they saw a PT first before a MD (Denninger et al. 2017)

Neck Pain – lifetime prevalence of up to 70%

            50-75% of patients report symptoms at 1 and 5 yr follow up (Hush et al. 2011, Carroll et al. 2006)

            Patients save $800 if they see a PT first before MD (Korthals de Bos et al. 2003)


            Manual Therapy more effective than primary care or exercise alone (Hoving et al. 2002, Gross et al. 2004).

            Beneficial effects seen up to 1 and 2 year follow up

Shoulder Pain – 2nd most common cause of musculoskeletal pain

            50% of patients report symptoms at 6 months (Winters et al. 1999)

            Physical Therapy accelerates recovery compared to usual medical care (Bergman et al. 2004)

            Physical Therapy reduces short and long term disability vs. primary care (Peek et al. 2015)

Elbow Pain

            Decreased healthcare utilization and costs with Physical Therapy treatment (Bisset et al. 2006)

            Lowest recurrence rate seen with PT treatments (Coombes et al. 2013)

Hip Osteoarthritis

            Physical Therapy delays need for hip replacement (Svege et al. 2015)
Knee Osteoarthritis

            Physical Therapy accelerates recovery vs. wait and see (Deyle et al. 2000)

            Manual therapy and exercise twice as effective as exercise alone (Deyle et al. 2005)

Ankle Sprains

            72% of patients report symptoms at 6 months (Braun et al. 1999)

            Physical Therapy accelerates recovery vs. rest, ice, compression, elevation (Green et al. 2001)








Choosing Physical Therapy First For Low Back Pain Saves $1500 Per Episode Of Care
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In previous blog posts, we have described the clinical and financial benefits of seeing a Physical Therapist first for treatment of neck or low back pain.  Patients who choose Physical Therapy first experience accelerated recoveries with decreased pain and recurrence rates compared to other providers.  In addition to the clinical benefits, this patient group is also less likely to undergo unnecessary, expensive, and risky interventions such as imaging, injections, and opioid medications.  Taken together patients seen by Physical Therapists first spend significantly less for the same or better recovery compared to other providers.

A recent article in the Journal of Orthopedic and Sports Physical Therapy followed 600 patients with either neck or low back pain to determine the cost and clinical effectiveness of seeing a Physical Therapist or Primary Care Physician for their care  (Denninger et al. 2017).  Authors reported patients see by direct access or patient self referral to Physical Therapy services spend on average $1543 less than those seen by a primary care physician.  Importantly, both groups demonstrated similar improvements in pain and disability.  This study highlights, the cost savings patients can experience if they choose Physical Therapy first for both their neck and low back pain.